Oppositional Defiant Disorder and Conduct Disorder in Children

Third, during the course of analyses we have conducted a number of statistical tests, taking alpha as. This increase the possibility that Type I errors may have been made in statistical inference. This highlights the importance of replication in research of this kind. Fourth, our parenting variables were measured with single items that may not have fully captured the dimensions of risk present in the population.

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This may limit the conclusions that can be made about relationships with these constructs. We approached this issue in a variety of ways. First, like other studies Loeber et al. We note, however, that earlier onset is a necessary condition for the developmental model, but is far from sufficient. Next, we confirmed that ODD symptoms at the first assessment wave were clear predictors of later CD symptoms in boys and girls, and found that wave 1 ODD diagnoses independently predicted later diagnoses of CD in boys but not girls.

Finally, we evaluated the relative frequency of this particular sequence of onsets that is, ODD preceding CD , given the range of potential onset sequences between two disorders that could, in principle, be observed. Taking this last approach, we found associations between the two disorders far less marked than might have been anticipated.

Viewed from another perspective, of all the CD cases only 9. In general, however, the overall pattern of our findings was consistent with results from other epidemiological studies Loeber et al. Among youth who did show both disorders, the retrospective age of onset data showed just more than half reported that an ODD symptom emerged prior to their first CD symptom. Our pathway analyses showed that the assumed transition from full disorder ODD to CD diagnosis was not common.

We considered a number of GSMS design features that might have contributed to this pattern of results.

Children Conduct Disorder Oppositional Defiant Disorder ODD

First, we checked whether selective attrition might have underestimated ODD development to CD but found no evidence to support this effect. Second, the CAPA uses a three-month reporting period. As a result, annual assessments may miss some periods of disorder and therefore underestimate prevalence in the population. This may be particularly relevant for CD as DSM-IV requires symptoms to be present at any point in a 12 month timeframe, so long as one is present within the previous 6 months.

In addition, year-on-year fluctuations whereby cases fall just above and just below diagnostic thresholds have been reported even in clinical samples Burke, in press. Each of these factors could have contributed to an underestimation of rates of disorder. To the extent that cases of ODD were missed we may have overestimated the proportion of cases in the CD only pathway. To the extent that cases of CD were missed, we may have overestimated proportions in the ODD only group. Comparative studies show no systematic difference between prevalence estimates derived from the CAPA and from other diagnostic approaches Maughan et al.

It is possible that measurement artifacts may have led to some underestimation of the prevalence of ODD and CD but any such effect was likely to have been minimal. A further — and possibly more salient — issue concerns the age-range covered by our observations. The age range covered in GSMS is a crucial period for the development of antisocial behavior, but clearly does not cover the full window of risk.

This could have a number of implications for our study. Although most GSMS observations were of children older than 10, first symptom onsets were typically reported to have occurred much earlier in childhood. We have no way of testing this possibility directly.

Younger samples will be required to test whether this pattern extends earlier into childhood. If replicable this might indicate that ODD is a stronger precursor to full disorder CD that onsets in childhood rather than adolescence. This possibility should be addressed in further research. As noted in the introduction, Lahey et al. In part, these discrepant findings seem likely to reflect the more severe difficulties indexed by a diagnostic measure than by questionnaire approaches. In addition, as outlined earlier, the measures used by Lahey et al.

Our own symptom count based analyses found ODD symptoms at wave 1 predicted later CD symptoms but did not identify the sex difference indicated in the diagnosis based analyses. ODD symptoms at wave 1 were similarly predictive of later CD symptoms for boys and girls even after control of wave 1 CD symptoms.

This discrepancy between diagnosis and symptom based analyses may be relevant to the debates on the utility of sex-specific diagnostic thresholds for CD Zoccolillo, In clinical practice, however, dichotomous decision making will continue to be required, for example in deciding whether and when to provide treatment. Identification of thresholds that are effective for both boys and girls is an important challenge for research.

When explored further in longitudinal analyses, CD at initial contact did not predict future onset of ODD once initial ODD symptomatology was controlled.

New guidelines on child antisocial behaviour

We compared these three groups in terms of exposure to a range of potential risk factors, comorbidities and psychiatric outcomes in early adult life. These results clearly highlight that ODD is a disorder worthy of clinical recognition rather than a feature of normal child development. In addition, we identified a number of features largely consistent with evidence from past reports that distinguished ODD and CD.

Risk factors, histories of parental antisocial behavior and mental health problems were closely similar in CD and ODD, as were elevated levels of exposure to social adversity and problems in family functioning. There were two exceptions to this pattern. This finding is also largely consistent with reports from other studies, although many have reported at least some tendency for more boys to meet criteria for ODD than girls.

It is possible that this represents a parental response to child oppositonality rather than a specific risk factor for ODD. Our final between-group contrasts centered on comorbidity with other disorders in childhood and adolescence and prediction to psychiatric outcomes in early adult life. Across all childhood and adolescent observations, rates of comorbidity were largely similar. Early adult outcomes provided a more differentiated picture.

In contrast, a history of ODD was associated with some increased risk for depression, and with markedly increased risk for anxiety in early adulthood. Strikingly, cases in the CD only group were at significantly lower risk for anxiety disorders than youth with no prior history of ODD or CD. Taken together, these findings on longer-term outcomes provide less support for a model of ODD as a milder form of CD, and point more in the direction of the two disorders representing distinct forms of psychopathology.

What is meant by conduct disorders?

Our final set of analyses was designed to test whether distinguishable dimensions of disorder could be identified within ODD. We examined whether there was empirical support for sub-factoring ODD symptoms that may in turn have implications for understanding links with CD. Our findings supported a two factor model with close similarities to the dimensions proposed by Stringaris and Goodman b on a priori theoretical grounds.

It is possible that a separate third factor would have been identified here if that approach had been taken. Future studies would benefit from including a greater range of items designed to measure each hypothesized dimension. Differences in analytic approaches and our focus on a community rather than a referred sample may have contributed to these variations. The headstrong dimension uniquely predicted the substance disorder outcome, however, while irritability uniquely predicted anxiety. We conducted some initial exploration of whether categorical diagnoses of ODD could be sub-typed on the basis of irritable and headstrong symptoms.

Using current diagnostic guidelines this was far from straightforward. Cases of ODD purely involving irritability cannot exist with a four symptom diagnostic threshold, and cases with only headstrong symptoms were exceedingly rare. In practice, most youth who met criteria for ODD showed a mix of these two symptom patterns. Person-centered approaches such as latent class analyses might provide a complimentary perspective to our findings and more complex approaches to sub-typing warrant further investigation. The links found here and elsewhere between irritability and affective disorder are consistent with the suggested mood diagnosis.

Further research will be required to identify whether the correlates and outcomes of TDD differ from the current specification of ODD and to identify the clinical characteristics of children with ODD who do not meet the TDD criteria. It is unclear whether similar sub-typing may be useful for ODD as well. Findings from community studies such as GSMS show a somewhat different pattern. Although there are strong overlaps between CD and ODD and developmental continuity at least in boys, these links are much weaker than those found in clinically referred samples.

As we have seen, however, this in no sense implies that cases meeting full criteria for ODD represent benign or transient disorders. Further studies are needed to clarify the processes underlying these links. As noted by Burke in press much past research has combined CD and ODD in epidemiological studies, hindering development of an evidence base on their differences. Fully separating the disorders for the latest revision will therefore improve the information available for the formulation of DSM-VI. National Center for Biotechnology Information , U. Author manuscript; available in PMC Nov 1.

Richard Rowe , PhD, E. Copyright and License information Disclaimer. The publisher's final edited version of this article is available at J Abnorm Psychol. See other articles in PMC that cite the published article. Method Sample The GSMS is a longitudinal study of the development of psychiatric disorder based in a predominantly rural area of the southern United States.

Open in a separate window. Early adult outcomes Psychiatric outcomes at ages 19 and 21 years are shown in Table 3. All models control for age and sex. Symptom dimensions in ODD In the final stage of the analyses we explored whether there were separable symptom dimensions within the ODD symptoms.

Table 4 Promax rotated factor loadings from an exploratory factor analysis of the ODD symptoms at wave 1. Symptom Irritable 1 Headstrong 1 Temper tantrums. Table 5 Prediction from a 1 SD increase in irritable and headstrong ODD symptom dimensions at wave 1 to later psychiatric outcomes up to age Manual for the child behavior checklist and revised profile. University of Vermont; Burlington: Diagnostic and statistical manual of mental disorders.

Angold A, Costello EJ. Toward establishing an empirical basis for the diagnosis of oppositional defiant disorder.

Nosology and measurement in child and adolescent psychiatry. Precision, reliability and accuracy in the dating of symptom onsets in child and adolescent psychopathology. Polyvagal Theory and developmental psychopathology: Emotion dysregulation and conduct problems from preschool to adolescence. Evidence from Longitudinal Clinical Studies. The behaviour of a child with conduct disorder may depend on their age.

Younger children aged under 11 may repeatedly argue with, disobey and defy those looking after them. NICE has made a number of recommendations about the diagnosis and treatment of conduct disorders. Its key recommendations are outlined below. One of the key messages contained in the NICE guidelines is the importance and usefulness of selective prevention. Selective prevention means identifying individual children with an above average risk of developing a conduct disorder and then providing treatment to try and prevent that from occurring. The rationale being that it is usually easier to prevent a disease than to cure one.

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NICE recommend that younger children aged three to seven years should be considered for selective prevention if:. NICE recommends that children or young people at risk of developing a conduct disorder or who are suspected of having a conduct disorder are assessed by qualified health or social care professionals. The initial assessment should then be followed by a more comprehensive assessment.

This should include asking about and assessing the following:. In younger children aged between three and 11 years, a type of treatment programme known as group parent training programme is recommended. In older children, aged from nine to 14 years, a type of treatment programme known as child-focused programmes are recommended. Older children and younger people aged years also benefit from what are known as multimodal interventions involving many services.

The programmes are run by specially trained health or social care professionals. They cover communication skills, problem-solving techniques and how to encourage positive behaviour in children. It is best if both parents, foster carers or guardians attend the programme if this is possible and in the best interests of the child or young person. Child-focused programmes involve group work with other children or young people of a similar age and similar issues.

The therapist encourages the children to better understand their thoughts, feelings and behaviour, and the connections between them. This is designed to help the children learn how to get along better with other people. The children usually meet with their group once a week for about 10 to 18 weeks.

Each meeting should last for about two hours. Multimodal interventions involve psychological therapies that encourage individuals to look at different aspects of their life and talk with a wider circle of people, including their family, people at their school or college and other people who are important in their life. This type of treatment should be provided by a specially trained professional called a case manager. The case manager should visit you three or four times a week for three to five months.

In cases where ADHD is thought to be a contributing factor, then medications used to treat ADHD, such as methylphenidate or atomoxetine, may be recommended. In a minority of cases, where a child or young person is finding it especially difficult to control their anger, a medication called risperidone, which helps reduce aggressive tendencies, may be recommended.

Children may initiate bullying and fighting, or animal cruelty. Children afflicted with ODD or Conduct disorder will most likely have trouble feeling empathy and may misread social queues or miss them altogether. He may misinterpret others behavior as hostile or aggressive leading him to act out in response to the aggression with aggression in return. Living with a child with either Conduct disorder or ODD is exhausting and sometimes heartbreaking.

Parents should get help, avoid power struggles, and remain positive with their child. Their child requires an extremely strict routine, consistency and positive reinforcement as well as a happy and refreshed parent who has confidence in themselves. The child will thrive in an environment which is healthy and did I mention consistent, consistent, consistent? I cannot emphasize that word enough. Parents and children will benefit from parental training. Parents and siblings should have patience as the treatment will include the whole family. When one child is disruptive, the entire family feels the effects and everyone suffers the consequences to a degree.

Once my son overcame his defiant behavior it was hard to imagine that my sweet child was once a monster and I sometimes wonder if exaggerated the whole thing.